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WAL-MART PHARMACY 10-5938
CH091080 SAN YSIDRO HEALTH CENTER
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Covered Entity Details
Entity Name
SAN YSIDRO HEALTH CENTER
Subdivision Name
San Ysidro Health San Ysidro Health Center
Type
HRSA-Funded Health Center
340B ID
CH091080
Entity Address
4004 BEYER BLVD
San Ysidro, CA 92173
Grant Number
H80CS10748
Participating Start Date
12/1/1992
Last Recertification Date
3/4/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5938
Pharmacy Address
575 SATURN BLVD
SAN DIEGO, CA 92154
Pharmacy Comments
Contract Details
Approval Date
7/8/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/10/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kevin Mattson, President & CEO
(619) 662-6322
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
7/8/2015
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